Parenteral Nutrition in

Palliative Care of Cancer

Patients

Federico Bozzetti

Faculty of Medicine, University of Milan, Italy

“Palliative care relieves suffering and

improves quality of life of the living and the

dying” (D Walsh, Palliative Medicine, Saunders 2009)

HPN in cancer patients in Europe*

• Low frequency (<10%) : Denmark, UK

• Intermediate frequency (10-50%): Spain,

France, Belgium

• High frequency (>50%): Netherlands, Italy

* F Bozzetti, M Staun, A Van Gossum

Home Parenteral Nutrition, CAB International 2006

How to explain discrepancy for

recommending HPN in different Institutions?

• Guidelines are inconsistent because:

- data are controversial

- grade A recommendations are missing because

RCTs in aphagic pts are not ethically possible

• PN is a therapy according to many scientific societies, but is an essential support according to the view of many patients, relatives and other non-scientific Institutions and opinion leaders

PN in incurable cancer patient: therapy,

support or something in between?

PN is a therapy

• Drug is any chemical agent

which affects living processes (Goodman&Gilman 1941)

• Physicians prescribe PN

• Physicians and medical societies consider nutrition as a therapy

• PN is a medical therapy for ill people

• It should be validated by RCT

PN is a support

• Also “natural” nutrition affects

living processes.(Paradoxically all humans got intrauerine PN)

• Dietitians prescribe PN in USA and patients and relatives often ask for it

• Nourishment is viewed by the relatives as an act of love and care

• Nutrition is essential both to ill and healthy people

• It is ethically impossible to have a no-PN arm and hence a GRADE A recommendation

PN in the incurable patient

Two opposite positions

• Cancer patients may die with the tumour,

but not because of the tumour

• Patients with benign intestinal failure

survive thanks to PN, cancer patients die

despite PN

A pragmatic approach: two main

questions

• Does HPN prolong survival in the aphagic

incurable cancer patient?

• Does HPN affect quality of life?

A pragmatic approach: two main

questions

• Does HPN prolong survival in the aphagic

incurable cancer patient?

• Does HPN affect quality of life?

From Lunney et al. JAMA 2003

“…

Potential role of PN in incurable

cancer patients

• Not in the imminently dying patient

• In some aphagic patients who are

expected to die from starvation prior than

from tumour progression and have an

acceptable quality of life

Natural history of patients with

inoperable malignant obstruction

Author Year N. pts Mean survival,

days

Tunca 1981 27* 33

Piver 1982 11* 60

Kreb 1983 14* <30

Gemlo 1986 27 60

Baines 1985 40 87

Rubin 1989 11* 54

* Ovarian cancer

Natural history of pts with inoperable

malignant obstruction receiving symptomatic

agents

Author Year N. pts Mean survival,

days

Hardy 1998 39 75

Laval 2000 58 41

Ripamonti 2000 17 11

Mercadante 2000 18 2-37

Mystakidou 2002 68 7-61

Survival of healthy subjects under total

macronutrient deprivation

63 days (BW loss 41%)°

57-73 days (BW loss 40%)°°

° American taylor starver

°° Irish hunger strikers

Survival of cancer patients on

HPN

Author N° PATIENTS SURVIVAL

Howard 1993 1672 28% at 1 yr;

median/mean 6/4 mos

Howard 1995 2122 37% at 1 yr

Messing 1998 524 19.5% at 6 mos

Van Gossum 1997 200 26% at 6-12 mos

Howard 2000 1073 25%at 1 yr; median 6

mos

SINPE Register 2004 1103 20% at 1 yr; median 6

mos

A pragmatic approach: two main

questions

• Does HPN prolong survival in the aphagic

incurable cancer patient?

• Does HPN affect quality of life?

CONTRIBUTION of DISEASE and

NUTRITION to QoL of H&N and GI

CANCER PTS (Ravasco et al 2004)

30% cancer site

20% CT,surgery, stage...

30% WL

20% Nutritional intake

QoL scores

Quality of Life in cancer patients on

HPN

• KPS increased in 7% of pts after 1 month and in 68%

after 3 months (Pironi 1999, Cozzaglio 1997)

• Capability to sustain daily activities improved in 27% of

patients (Torelli 1999)

• Full rehabilitation at 1 year in 31% of patients (Howard

1993)

Quality of life and length of survival in advanced cancer on HPN

Bozzetti F., Cozzaglio L., Biganzoli E. et al.

Clin Nutr. 2002; 2: 281-8.

69 (sub)obstructed patients on HPN

Parameters of evaluation

• nutritional status

• survival

• KPS

• Rotterdam Symptom Checklist Questionnaire

(39 questions on psychological and physical status and level

of activity)

Quality of life and length of survival in advanced cancer on HPN

Bozzetti F., Cozzaglio L., Biganzoli E. et al.

Clin Nutr. 2002; 2: 281-8.

RESULTS

• Median survival 4 months (r. 1-14)

• One third survived > 7 months

• Nutritional indexes stable until death

• QoL scores declined 2-3 months before

death

1

2

3

4

5

6

7

8

9

10

11

12

13

-50 -40 -30 -20 -10 0 10

Variation in Karnofski Performance Score

Mo

nth

s to

de

ath

1

2

3

4

5

6

7

8

9

10

11

12

13

-20 0 20 40

Variation in QoL Total Score

Mo

nth

s to

de

ath

EXPECTED BENEFIT ON SURVIVAL

OF HPN IN APHAGIC CANCER

PATIENTS

Survival of healthy people during total starvation:

63 days (BW loss 41%)°

57-73 days (BW loss 40%)°°

Survival of patients with malignant obstruction

usually < 2 months

Survival of aphagic cancer patients on HPN°°°:

73% at 2,1/2 months (30% at 6-7 months)

median: 4 months

Acceptable QoL till 2-3 months before death

° American taylor starver

°° Irish hunger strikers

°°° SINPE 1997

CURRENT INDICATIONS FOR A HPN

PROGRAMME

• Unable to eat mainly for GI (sub)ostruction

• Life expectancy due to the cancer >3 mos (?)

• No or minimal involvement of vital organs and no functional organ deterioration

• No pleural or peritoneal effusion

• PS =/>50

• Absence of important and/or poorly-controlled symptoms

• Previous consent of the patient&relatives to modify and substantially reduce the nutritional regimen should a functional deterioration occur

ESPEN HAN WG Protocol in incurable

cancer patients on HPN

Aims

to define predictive factors for survival >3 and >6 mos

Variables

nutritional, clinical, oncological, biochemical

Centres 9 (Italy, Spain, Poland, Germany, Denmark, UK, Canada)

Status

> 200 patients enrolled (analysis in the 2011)